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INTRODUCTIONFunctional dentition is an important factor in theprocess of growth and development of the childpatient, therefore preservation of both primary andpermanent teeth in a functional state is a major task inachieving good oral health in children.1

Many risk factors have been found to affect the healthof dental pulp and consequently cause pulpal infection.Of these factors, dental caries, periodontal disease anddental trauma have been generally reported to be themajor and the commonest causes of pulp necrosisand periapical periodontitis.2,3,4 In Nigeria, studies haveshown that the commonest cause of tooth loss amongchildren is delayed presentation of dental caries andtraumatic dental injury.5,6,7 This late presentation andsymptomatic visits attitude has made endodontictreatment inevitable among them.

Endodontic treatment is a procedure that is designedto maintain the health of all or part of the pulp whenthe pulp is diseased or injured, thereby preserving thetooth that would have been otherwise extracted dueto pulpal pathology.8 In a study carried out amongDanish population, Kirkevang et al.9 reported thatendodontic treatment has invariably led to a decline inthe tendency amongst dentists to extract diseased teeth.These treatments aim at prevention of progressionof infection, preservation of normal periradiculartissues and restoration of the treated tooth to its properform and function in the dental arch.10

Endodontic treatment comprises pulp capping,pulpotomy, pulpectomy, apexification, root canaltherapy and surgical endodontics such as apicectomy,hemisection, root amputation and replantation.2,11

ENDODONTIC TREATMENT IN CHILDREN: A FIVE-YEAR RETROSPECTIVESTUDY OF CASES SEEN AT THE UNIVERSITY COLLEGE HOSPITAL, IBADAN,

NIGERIAB.O. Popoola, O.E. Ayebameru and O.M. Olanloye

Department of Child Oral Health, University of Ibadan/University College Hospital, Ibadan.

Correspondence:Dr. O.E. AyebameruDepartment of Child Oral Health,University College Hospital,IbadanE mail: brodashow@yahoo.com

ABSTRACTBackground: Endodontic treatment aims at preservation of teeth that are pulpallydamaged, consequently make the teeth functional on the dental arch.Objective: This study aimed at determining the prevalence and pattern ofendodontic treatment carried out at the Paediatric dental unit of the UniversityCollege Hospital, Ibadan over a five-year period.Materials and methods: This was a retrospective study of all patients below 16years of age treated for various dental problems in our unit between August, 2010and July, 2015. The records were reviewed and cases with endodontic treatmentsselected. Data such as age, gender, endodontically treated teeth, reasons forendodontic treatment and type of endodontic treatment given were retrievedfrom the patients’ dental records.Results: A total of 3,237 children were seen during the period under review, outof which 312 (9.6%) received endodontic treatment. There were 159 males and 153females with a mean age of 10.2 ± 3.5. Children aged 10-13 years had the highestfrequency of endodontic treatment (36.8%) and this was majorly due to dentaltrauma, followed by those aged 6-9 years (28.6%) who were treated mainly fordental caries. Root canal therapy was the most prevalent endodontic treatment inpermanent teeth (central incisor; 32.7% and first permanent molars; 14.6%) whilepulpectomy was the most prevalent endodontic treatment in primary teeth (p = <0.001).Conclusion: Dental caries and trauma were the commonest reasons for endodontictreatment in primary and permanent teeth respectively. The prevalence ofendodontic treatment in the studied children was 9.6% with highly invasive andmultiple visits endodontic treatment type (pulpectomy and root canal therapy)being the most common. There is a need for early presentation of dental conditionsso as to reduce complications which require such endodontic treatments.

Keywords: Endodontics, Children, Dental caries, Trauma.

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Recently, regenerative endodontics which is based ontissue engineering and root canal revascularization wasintroduced to overcome the limitations of apicectomyand apexification in the management of immaturetooth with open apex and necrotic pulp.12

The prevalence and pattern of endodontic treatmenthas been studied among many adult populations,irreversible pulpitis due to dental caries was found tobe the leading reason for endodontic treatmentperformed.13-19 A similar study among childrenpopulation also reported dental caries as thecommonest reason for endodontic treatment whileother reasons identified were trauma anddevelopmental anomalies such as dens invaginatus.20

However , previous studies among Nigerian childrenrevealed that traumatic dental injuries was the mostcommon reason for endodontic treatment in thesechildren.21-25 Although in contrary, Ajayi et al.2 alsoreported dental caries as the dominant reason forendodontic treatment among the studied children inLagos, Nigeria. The University College Hospital,Ibadan, Nigeria is a tertiary hospital that has well -established dental centre with well-equipped paediatricdentistry clinic which serves Ibadan and its environs.This retrospective study had the objective ofdetermining the prevalence and pattern of endodontictreatment performed in the past five years in thePaediatric dentistry unit of the hospital. This will serveas baseline data from which reference can be madeon endodontic treatment acceptability among childrenin our environment.

MATERIALS AND METHODSA retrospective study involving patients below 16 yearsof age who attended the paediatric dental clinic ofUniversity College Hospital, Ibadan between August,

2010 and July, 2015. Dental records of all patientsseen within the study period were retrieved and thosewith endodontic treatment were selected. Thefollowing information were retrieved from the selectedcases; age, sex, type of endodontically treated tooth,reasons for endodontic treatment and type ofendodontic treatment given. Data obtained wereanalyzed using SPSS Version 20.0. Descriptive statisticswas used to summarize the variables in the data set.Chi-square test was employed to test associationinvolving discrete data with the level of significanceset at p<0.05.

RESULTSA total of 3,237 children aged 2-16 years were treatedat the Paediatric dental clinic of the University CollegeHospital between August 2010 and July 2015, out ofwhich three hundred and twelve (9.6%) of thesechildren received endodontic treatment. Among thosewho had endodontic treatment, one hundred and fifty-nine (51.0%) were males while 153 (49.0%) werefemales with a mean age of 10.2 ±3.5 years. Reasonsfor endodontic treatment based on gender and agegroups are as shown in Table 1.

More males had endodontic treatment on account oftrauma while more females had endodontic treatmenton account of caries. There was no significantdifference in the reason for endodontic treatment basedon gender. It was noticed that a greater proportion ofchildren in the younger age groups (2-5, 6-9 years old)had endodontic treatment on account of caries (30.1%)while majority of those in the higher age groups (10-13, 14-16 years old) had endodontic treatment onaccount of trauma (37.4%).Children within the agegroup 10-13 years had the highest frequency ofendodontic treatment (36.8%) followed by the agegroup 6-9 years (28.6%) (Table 1)

Table 1: Reasons for endodontic treatment according to gender and age groupsDental caries Dental trauma Total P valuen(%) n(%) N(%)

GenderMaleFemaleTotal

71(22.8)90(28.8)

161(51.6)

88(28.2)63(20.1)

151(48.4)

159(51.0)153(49.0)312(100.0)

0.390

Age groups (Years)2 – 56 – 910 -1314 – 16Total

34(10.9)60(19.2)35(11.2)32(10.3)

161(51.6)

5(1.6)29(9.4)

80(25.6)37(11.8)151(48.4)

39(12.5)89(28.6)

115(36.8)69(22.1)

312(100.0)˂ 0.001

Categorized AgeLower (2-5, 6-9)Higher (10-13, 14-16)Total

94(30.1)67(21.5)

161(51.6)

34(11.0)117(37.4)151(48.4)

128(41.1)184(58.9)312(100.0) ˂ 0.001

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With regards to endodontically treated teeth duringthe study period, a total of 404 teeth were treated.One hundred and twenty two primary teeth wereendodontically treated while 282 permanent teeth wereendodontically treated. Among the primary teeth, thefirst and second molars were the most frequentlytreated (88.6%) with the mandibular molars more

involved than the maxillary molars (59.0 %/29.5%).The difference in the teeth treated was statisticallysignificant (p= < 0.001). Dental caries was thecommoner reason for endodontic treatment in primaryteeth in both anterior and posterior region and thiswas statistically significant (p= 0.001). Conversely, inthe permanent dentition, the most affected anterior

Table 2: Endodontically treated deciduous teeth based on their location and reasons for treatmentN = 122(100%)

A= Primary central IncisorsB= Primary lateral incisorsD= Primary first molarE= Primary second molars

1 = Permanent central Incisors2 = Permanent lateral Incisors6 = Permanent first molars7 = Permanent second molars

Table 3: : Endodontically treated permanent teeth based on their location and reasons for treatmentN = 282(100%)

Mandible Maxilla Total p-valueN(%)

Cariesn (%)

Trauman(%)

Cariesn(%)

Trauman(%)

Tooth type

A 0(0.0) 0(0.0) 8(6.6) 4(3.3) 12(9.8)

<0.001B 0(0.0) 0(0.0) 2(1.6) 0(0.0) 2(1.6)D 32(26.2) 0(0.0) 6(4.9) 0(0.0) 38(31.2)ETotal

40(32.8)72(59.0)

0(0.0)0(0.0)

30(24.6)46(37.7)

0(0.0)4(3.3)

70(57.4)122(100.0)

Mandible Maxilla Total p-valueN(%)

Cariesn (%)

Trauman(%)

Cariesn(%)

Trauman(%)

Tooth type1 2(0.7) 12(4.3) 15(5.3) 149(52.8) 178(63.1)

<0.0012 2(0.7) 3(1.1) 6(2.1) 17(6.0) 28(9.9)6 44(15.6) 0(0.0) 21(7.5) 0(0.0) 65(23.1)7 9(3.2) 0(0.0) 2(0.7) 0(0.0) 11(3.9)Total 57(20.2) 15(5.3) 44(15.6) 166(58.9) 282(100.0)

Pulpotomyn (%)

Pulpectomyn (%)

Totaln (%)

ToothABDETotal

0(0.0)0(0.0)

13(34.2)31(44.3)44(36.1)

12(100.0)2(100.0)

25(65.8)39(55.7)78(63.9)

12(100.0)2(100.0)

38(100.0)70(100.0)

122(100.0)

Table 4: Endodontic treatments done on deciduous teeth N = 122(100%)

A= Primary central IncisorsB= Primary lateral incisorsD= Primary first molarE= Primary second molars

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teeth were the central incisors especially maxillarycentral incisors (due to dental trauma) while in theposterior teeth, the first permanent molars mainly themandibular first permanent molars (due to dental caries)were the most involved.

However, more permanent teeth were endodonticallytreated as a result of dental trauma than dental cariesand this was also statistically significant (p=< 0.001)

Among the deciduous teeth, 63.9%of the endodontictreatment was pulpectomy, while 36.1% waspulpotomy. In the permanent dentition, Root canaltherapy was the most common endodontic treatment(70.9%) performed followed by apexogenesis andapexification (23.0%). Table 4.

DISCUSSIONIn this study, 9.64% of all the children that presentedin the paediatric dentistry clinic had endodontic therapyon account of dental caries or trauma. The mean ageof these children was 10.2±2.5 years. There was nogender predilection, a finding similar to those reportedby Ajayi et al.2 and Barbakov et al.27 However, Hina etal.3 in their study observed female preponderance whileother studies by Hull et al.28 and Sabahat et al.4 reporteda male preponderance. The lack of sex preponderancein this study may be due to late presentation of thechildren which invariably determines the treatment planfor these children irrespective of their gender.

Furthermore, despite the lack of sex preponderance,the reason for endodontic treatment differed. Dentaltrauma was the commonest reason for endodontictreatment in males while dental caries was thecommonest reason in females. This disparity may bedue to the fact that male children are more physicallyactive hence, have an increased susceptibility to falls

and other forms of injuries while the female childrenare prone to dental caries due to excessive snackingon cariogenic diets.5

In the primary dentition, dental caries was found tobe commonest reason for endodontic treatment witha peak age range of 6-9years. This finding is similar tothose reported in previous studies where dental carieswas the main reason for endodontic treatment inchildren.2, 5, 20 It may be associated with the fact thatprimary dentition is regarded as unimportant dentitionthus the patient only report in the clinic when painfrom such carious teeth become unbearable or areassociated with severe morbidity.2 At the time ofpresentation, the carieous lesion would have advancedwell into the pulp thus requiring advanced endodonticinterventions.

More mandibular primary teeth had endodontictreatment relative to the maxillary teeth with the lowersecond molar being the commonest teeth to undergoendodontic treatment. This is in agreement with otherstudies.2 The susceptibility of the lower teeth to cariesmay be associated with the relative ease of foodpacking and plaque accumulation in the mandibularposterior region.2 The vulnerability of the secondprimary mandibular molars to advanced caries maybe due to its occlusal fissure topography. The occlusalpits and fissures of these teeth are deeper and lesscompletely coalesced thereby acting as stagnation areaswhere accumulated bacteria are not easily removed.29

In permanent dentition, trauma was found to be thecommonest reason for endodontic treatment with apeak age range of 10-13years and the incisors are themost common endodontically treated teeth. Thisfinding similar to those reported by Sote et al., 30 wherethe incisor was the most root filled tooth but differs

Pulpcapping

Apexogenesis/Apexification RegenerativeEndodontics

Root CanalTherapy

Total

n (%) n (%) n (%) n (%) n (%)Tooth1267Total

2(1.1)2(7.1)6(9.2)2(18.2)

12(4.3)

41(23.0)24(85.8)0(0.0)0(0.0)

65(23.0)

3(1.7)2(7.1)0(0.0)0(0.0)5(1.8)

132(74.2)0(0.0)

59(90.8)9(81.8)

200(70.9)

178(100.0)28(100.0)65(100.0)11(100.0)

282(100.0)

Table 5: Endodontic treatments done on permanent teethN = 282(100%)

1 = Permanent central Incisors2 = Permanent lateral Incisors6 = Permanent first molars7 = Permanent second molars

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from that of Ajayi et al.,2 where the first molar was themost root filled tooth. The difference in the findingsmay be attributed to the fact that in the present studiedpopulation, the prevalence of trauma was high.

However, when the posterior region in the permanentdentition was considered, it was observed that dentalcaries was the main reason for endodontic treatmentand the mandibular first permanent molars were mostlyaffected. This finding is similar to those reported inliterature.2,30 The susceptibility of the mandibular firstpermanent molar can be attributed to their earlyeruption which may have subjected them to thecariogenic oral environment for a long time than otherposterior permanent teeth.4 Moreover, it is possiblethat being the first set of permanent teeth to erupt inthe mouth many parents may fail to recognize them aspermanent teeth and thus neglect them through badoral health practices such as ineffective oral hygienemeasures.31 Another reason for their susceptibility maybe related to their prolonged period of eruption whichmakes oral hygiene measures ineffective.31

Of all the various endodontic treatment modalities inthe primary dentition, pulpectomy was the commonesttreatment carried out. This finding is different fromthat of Ajayi et al., where pulpotomy was the majorendodontic treatment carried out. This difference maybe attributed to the fact that children in this studypresent very late when the disease process would haveadvanced thereby necessitating this type of endodontictreatment in contrast to those of Ajayi et al., wheremore children presented at an early stage when thedisease was still confined to the coronal pulp.Meanwhile in the permanent dentition root canaltherapy was the commonest endodontic treatmentoffered, a finding similar to those reported in previousstudies and this may also be related to latepresentation.2,30

In conclusion, dental caries and trauma are thecommonest reasons for endodontic treatment inprimary and permanent teeth respectively. When dentalcaries was the reason for endodontic treatment, themandibular molars were the most involved while whentrauma was the reason for treatment, the incisors werethe most involved.

In both dentitions, advanced endodontic treatmentswere the most commonly performed treatment whichsuggests that at the time of presentation, the diseaseprocess had advanced. Thus there is a need to educatechildren and their parents on the importance of earlypresentation to the dental clinic and the possible sequelof late presentation in terms of morbidity, cost andtime.

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